Town of Rochester
Community Center/Youth Department
PO Box 65, Accord, NY 12404
Office Phone: (845) 626-2115 Fax (845) 626-0141 Youth Center Phone (845) 626-3053
Carol Dennin, Director
Valerie Weaver, Assistant Director
Funded by New York State Office of Children & Family Services
This program does not deny services to participants regardless of race, creed, color, national origin, sex, or disability.
Registration Form 
Received
Today’s Date: _______________________
Name: _________________________________________________________________
Address: _______________________________________________________________
City/ Town/ State/ Zip:_____________________________________________________
Age ______ Date Of Birth: _________________ Gender: ____ School: ________________
Ethnicity: White ___ Black___ Hispanic___ Native American__ Asian __Other___
Name Of Parents/ Guardians: _______________________________________________________
Telephone # (Home): __________________ Cell: _________________ Work: ________________
Do you have any allergies? _________________________________________
Are you taking any medication? _____________________________________
Do you have any disabilities and/or health conditions that we should know about? _____________
Days and hours available: _______________________________________________________________________________
Circle Jobs preferred:
General House Cleaning
Babysitting
Mother’s Helper
Yard Work
Pet-sitting
Greenhouse/Gardening
Basements/Attics
Cleaning Pools
Cleaning garages
Snow shoveling
Other preferences: _____________________________________________________________
Special skills: ____________________________________________________________________
Will you need transportation? ______________________________________________________
Youth Department
Town Of Rochester
845-626-2115
I, as parent/guardian of _____________________________________________________
Name of Child
do hereby recognize that the Rent-A-Kid Program is not an employer, but merely a referral service. (To help ensure your child’s safety we advise all parents to meet with perspective employers. We do not do a background check on individuals calling for employment services. Keep our children safe.)
I further recognize that the Town of Rochester Youth Department is to receive no fee, compensation, and other benefit either from my child, or from any perspective employer for performing employment referral services.
In consideration of the Rent-A-Kid Program accepting my child for referral to various employment positions, I hereby agree to waiver and release the Town of Rochester Youth Department from any liability of any nature whatsoever resulting from my child’s employment in a position or job secured by or through referral from Rent-A-Kid.
_______________________________________
Signature of Parent or Guardian
________________________________________
Address (Street)
__________________________________________
Address (City) (State) (Zip)
__________________________________________________________
Phone number
__________________________________________________________
Date
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